Individuals who are dying do not move toward death at the same rates or in the same ways. Different causes of death are associated with different patterns of dying.[1] These patterns, referred to as dying trajectories, indicate the path of an individual’s experience of dying. The attitudes and behaviors of people caring for the patient are strongly influenced by their perceptions of the patient’s dying trajectory. Trajectories will also affect the types of emotional responses and coping mechanisms displayed by patients and their families, as well as the interventions that will be initiated. For these reasons, the purpose of understanding one’s dying trajectory is to anticipate and implement appropriate interventions. Uncertain trajectories are more difficult to cope with than are certain trajectories because ambiguity generates anxiety.

The dying process can be described in terms of duration and shape. Duration refers to the time between the onset of dying and the arrival of death. Shape designates the course of the dying process (i.e., whether one can predict how the process will advance and whether the approximate timing of the death is expected or unexpected).

The following examples of trajectories have been described:

• The gradual slant is characterized by a long, slow decline, sometimes lasting a period of years.



• The downward slant is represented by a rapid decline toward death in which the chronic phase of the illness is either short or nonexistent.



• The peaks and valleys trajectory is marked by alternating patterns of remission and relapse.



• The descending plateaus trajectory is indicated by long, slow periods of decline followed by restabilization. Patients in this trajectory must repeatedly adjust to different levels of functioning.

Deaths associated with cancer are often lengthy processes and may be linked with long-term pain and suffering and/or a loss of control over one’s body or mental faculties. Protracted deaths are more likely to drain a family’s physical and emotional resources because caregivers are required to provide care for longer periods of time. The spectrum of chronic care needs of these patients and their caregivers may benefit from referral to a palliative care service, which may provide resources more appropriate to their needs than those provided by the more cure-centered focus of high-tech medical facilities.[2] In one Italian study of caregivers of home-treated patients with advanced cancer, bereavement maladjustment problems at 12 months after a patient's death correlated with self-reports of emotional distress and with caregiving-related problems detected at the time of referral to the palliative care unit home care program. Identification of such predictors may facilitate the development of interventions for at-risk individuals.[3]

References

1. Glaser BG, Strauss AL: Time for Dying. Chicago: Aldine, 1968. 
   
   
2. McGrath P: Caregivers' insights on the dying trajectory in hematology oncology. Cancer Nurs 24 (5): 413-21, 2001.  [PUBMED Abstract]
   
   
3. Rossi Ferrario S, Cardillo V, Vicario F, et al.: Advanced cancer at home: caregiving and bereavement. Palliat Med 18 (2): 129-36, 2004.  [PUBMED Abstract]